REPUBLIC OF THE PHILIPPINES)

CITY OF _____________________) Sc.

x------------------------------------------x

AFFIDAVIT

I, ___________________, Filipino, of legal age, single and a resident of

___________________, after being duly sworn to in accordance with law, depose and
state that:

1. As a _____________, I was issued a ____________ with No. ____________;

2. On or about ____________, I discovered that my said __________ was missing

and I exerted all efforts to locate the same but I could no longer find it;

3. Said _______________ has not been confiscated by any officer of the law or by
the officers of ______________ for violation of any law, ordinance, decree or the
rules and regulations of ______________;

4. As all diligent search and efforts to find the same proved futile, it is now safe to
assume that said ____________ is now lost beyond recovery;

5. As such, I execute this affidavit to attest to the truth of the foregoing facts, to
support my application for the issuance of a new _____________, and for
whatever legal purpose that this affidavit may serve;

6. FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________

in the City of ______________, Philippines.

_____________________________
AFFIANT

SUBSCRIBED and sworn to before me on the date and place first above written
by the above-named Affiant whom I have identified through his _______________
which is valid until ________________.

NOTARY PUBLIC

Doc. No. _____;

Page No. _____;
Book No._____;
Series of 20___.